78R5866 AKH-D

By:  Hopson                                                       H.B. No. 1238


A BILL TO BE ENTITLED
AN ACT
relating to the prompt payment of certain pharmacy claims by health maintenance organizations and preferred provider benefit plans. BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: SECTION 1. Section 3A, Article 3.70-3C, Insurance Code, as added by Chapter 1024, Acts of the 75th Legislature, Regular Session, 1997, is amended by amending Subsection (d) and adding Subsection (o) to read as follows: (d) Not [If a prescription benefit claim is electronically adjudicated and electronically paid, and the preferred provider or its designated agent authorizes treatment, the claim must be paid not] later than the 21st day after the date an insurer affirmatively adjudicates a pharmacy claim that is electronically submitted, the insurer shall: (1) pay the total amount of the claim through electronic funds transfer; or (2) notify the pharmacy provider of the reasons for denying payment of the claim [treatment is authorized]. (o) A transaction fee may not be charged for adjudication of a claim submitted electronically. SECTION 2. Section 843.339, Insurance Code, as effective June 1, 2003, is amended to read as follows: Sec. 843.339. DEADLINE FOR ACTION ON CERTAIN PRESCRIPTION BENEFIT CLAIMS. (a) Not [If a health maintenance organization or its designated agent authorizes treatment, a prescription benefit claim that is electronically adjudicated and electronically paid shall be paid not] later than the 21st day after the date a health maintenance organization or the health maintenance organization's designated agent affirmatively adjudicates a pharmacy claim that is electronically submitted, the health maintenance organization shall: (1) pay the total amount of the claim through electronic funds transfer; or (2) notify the pharmacy provider of the reasons for denying payment of the claim [on which the treatment is authorized]. (b) A transaction fee may not be charged for adjudication of a claim submitted electronically. SECTION 3. This Act takes effect September 1, 2003, and applies only to a payment to a pharmacy provider for claims submitted to a health maintenance organization or an insurer on or after that date.